repetitive strain injury

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Repetitive strain injury (RSI), also known as Cumulative Trauma Disorder (CTD), occupational overuse syndrome, non-specific arm pain^[1] or work related upper limb disorder (WRULD), any joint pain that is believed to be caused by chronic misuse of these body parts, for instance, while using a computer on the job. Conditions such as RSI tend to be associated with both physical and psychosocial stressors.^[2]

The Illness

Symptoms

The following complaints are typical in patients that might receive a diagnosis of RSI:^[3]

• Pain in the arm (typically diffuse—i.e. spread over many areas).
• The pain is worse with activity.
• Weakness, lack of endurance.

In contrast to carpal tunnel syndrome, the symptoms tend to be diffuse and non-anatomical, crossing the distribution of nerves, tendons, etc. They tend not to be characteristic of any discrete pathological conditions.

Frequency

A 2008 study showed that 68% of UK workers suffered from some sort of RSI, with the most common problem areas being the back, shoulders, wrists, and hands.^[4]

Physical Examination and Diagnostic Testing

The physical examination discloses only tenderness and diminished performance on effort-based tests such as grip and pinch strength—no other objective abnormalities are present. Diagnostic tests (radiological, electrophysiological, etc.) are normal. In short, RSI is best understood as an apparently healthy arm that hurts. Whether there is currently undetectable damage remains to be established.

Defining RSI

The term "repetitive strain injury" is most commonly used to refer to patients in whom there is no discrete, objective, pathophysiology that corresponds with the pain complaints. It may also be used as an umbrella term incorporating other discrete diagnoses that have (intuitively but often without proof) been associated with activity-related arm pain such as Carpal tunnel syndrome, Cubital tunnel syndrome, Thoracic Outlet Syndrome, DeQuervain's syndrome, Stenosing tenosynovitis/Trigger finger/thumb, Intersection syndrome, Golfer's elbow (medial epicondylosis), Tennis elbow (lateral epicondylosis), and Focal dystonia.

Finally RSI is also used as an alternative or an umbrella term for other non-specific illnesses or general terms defined in part by unverifiable pathology such as Reflex sympathetic dystrophy syndrome (RSDS), Blackberry thumb, disputed Thoracic Outlet Syndrome, Radial tunnel syndrome, "Gamer's thumb" (a slight swelling of the thumb caused by excessive use of a gamepad), "Rubik's wrist" or "cuber's thumb" (tendinitis, carpal tunnel syndrome, or other ailments associated with repetitive use of a Rubik's Cube for speedcubing), "Stylus Finger" (Swelling of the hand caused by repetitive use of mobile devices and mobile device testing.), "Raver's wrist", caused by repeated rotation of the hands for many hours (for example while holding glow sticks during a rave).

Although Tendinitis and Tenosynovitis are discrete pathophysiological processes, one must be careful because they are also terms that doctors often use to refer to non-specific or medically unexplained pain, which they theorize may be caused by the aforementioned processes.

Treatment

Ergonomics

Modifications of posture and arm use (ergonomics) are often recommended.^[5]

Ergonomics: the science of designing the job, equipment, and workplace

Adaptive technology

Adaptive technology ranging from special keyboards, mouse replacements and pen tablet interfaces to speech recognition software might be necessary:

Break Timers

Pause software reminds the user to pause frequently and perform exercises while working behind a computer. One such program is Workrave, an open-source free program that assists in the recovery and prevention of Repetitive Strain Injury. The program frequently alerts user to take micro-pauses, rest breaks and restricts user to a predefined daily limit. A similar program is RSI reminder, by Rob Nebeker; the program is available as a widget (i.e., add-in) for the Google Desktop.

Mice

Switching to a much more ergonomic mouse, such as a RollerMouse, vertical mouse or joystick, or switching from using a mouse to using a stylus pen with graphic tablet may provide relief, but in chronic RSI they may only result in moving the problem to a different area. Using a graphic tablet for general pointing, clicking, and dragging (i.e. not drawing) may take some time to get used to as well. Switching to a trackpad, which requires no gripping or tensing of the muscles in the arms may help as well. Inertial mice (which do not require a surface to operate) might offer an alternative where the user's arm is in a less stressful thumbs up position rather than rotated to thumb inward when holding a normal mouse. Also, since they do not need a surface to operate ("air mice" function by small, forceless, wrist rotations), the wrist and arm can be supported by the desktop or

Keyboards and Keyboard-alternatives

Switching to a much more ergonomic keyboard layout such as Dvorak^{[citation needed]} or Colemak may help.

Exotic keyboards by manufacturers such as DataHand, OrbiTouch, Maltron and Kinesis are available.

DataHand Professional II Keyboard, left side

Medical

A number of medical treatments, including non-narcotic pain medications, braces, and therapy, exist although some doctors consider these to be palliative.^[6][7](See Are Some RSI Cases Psychosomatic? below)

Exercise

Exercise decreases the risk of developing RSI.^[8]

• Given that main stream health providers are still working on the best approach to RSI, it is not surprising that alternative treatments are popular. Some people with RSI find relief in specific movement therapies such as taijiquan （太極拳, t'ai chi ch'üan), yoga, or the Alexander technique.
• Doctors often recommend that RSI sufferers engage in specific strengthening exercises, for example to improve posture.
• In light of the fact that a lifestyle that involves sitting at a computer for extended periods of time increases the probability that an individual will develop excessive kyphosis, theoretically the same exercises that are prescribed for thoracic outlet syndrome or kyphotic postural correction would benefit an RSI sufferer.^[9]

Resume Normal Activities Despite the Pain?

Some researchers believe that, for the most difficult chronic RSI cases, the pain itself becomes less of a problem than the disruption to the patient's life caused by

• avoidance of pain-causing activities
• massive investment of time into increasingly futile attempts at treatment

They claim greater success from teaching patients psychological strategies for accepting the pain as an ongoing fact of life, enabling them to cautiously resume many day-to-day activities and focus on aspects of life other than RSI.^[10]

Others disagree, emphasizing the importance of rest in achieving recovery. For instance, it has been claimed that recovery can take up to 8 months without performing activities that might exacerbate the symptoms, and that the affected joint should never be put under severe or constant stress.^{[citation needed]}

Psychosocial Factors

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Population Studies

Studies have related RSI and other upper extremity complaints with psychological and social factors. A large amount of psychological distress showed doubled risk of the reported pain, while job demands, poor support from colleagues, and work dissatisfaction also showed an increase in pain, even after short term exposure.^[11]

For example, the association of Carpal tunnel syndrome with arm use is commonly assumed but not well-established.^[12] Typing has long been thought to be the cause of carpal tunnel syndrome,^[13] but recent evidence suggests that, if anything, typing may be protective.^[14] Another study claimed that the primary risk factors for Carpal tunnel syndrome were "being a woman of menopausal age, obesity or lack of fitness, diabetes or having a family history of diabetes, osteoarthritis of the carpometacarpal joint of the thumb, smoking, and lifetime alcohol intake."^[15]

Psychological Exacerbation of Symptoms

There are three common mechanisms, by which a normally functioning human mind increases pain and pain-related disability.

• Psychological distress (depression and anxiety) make pain seem worse.^[16] Chronic pain, regardless of its source, leads to a cycle of increasing depression and reduced physical activity. Reduced physical activity reduces pain in the short term but increases it in the long term.^[17]
• Misinterpretation or over-interpretation of pain signals. Psychologists refer to this as pain catastrophizing (the tendency to think the worst when one feels pain),^[3] and it is worsened by reliance on patient support groups and internet sites for diagnosis.^[18] Gate Control Theory, part of the most accepted medical theory of pain, states that, when we are worried about a particular body part, the brain can actually signal to the spinal cord (via outgoing neurons) that it should be more apt to interpret nerve impulses from that body part as pain and pass them on to the brain.^[19]. In patients with chronic arm pain, the brain may even learn to automatically trigger pain whenever the limb is moved, as a defense mechanism to prevent further movement^[20]
• A sense that something is seriously wrong that does not lessen with normal test results and reassurance from health professionals.^[21] Psychologists call this heightened illness concern or health anxiety. (This is commonly seen in psychosomatic illnesses.^[22].) The typical RSI patient presents with a strong intuition that their pain indicates existing and ongoing tissue damage.^[21] One explanation is that they have a strong "pain alarm"--pain tends to be accepted as a sign of danger and they have difficulty modulating this intuitive uneasiness with pain.^[3].

Are Some RSI Cases Psychosomatic?

Some doctors and medical researchers believe that stress is the main cause, rather than a contributing factor, of a large fraction of pain symptoms usually attributed to RSI. The most famous advocate of this point of view, Dr. John E. Sarno, Professor of Rehabilitation Medicine at the New York University Medical School considers that RSI, back pain, and other pain syndromes, although they sometimes have a physical cause, are more often a manifestation of tension myositis syndrome, a psychogenic disorder in which stress causes the autonomic nervous system to reduce blood flow to muscles, causing pain and weakness.^[23]

RSI shares many characteristics with known psychosomatic disorders:

• Freud and other psychiatrists believe that diffuse, difficult to describe symptoms likely indicated a psychosomatic root cause for an illness, especially if they moved around the body.^[24] (Only some RSI cases fit this description.)
• Psychosomatic illnesses typically display symptoms whose origins are unverifiable but which seem consistent with the time period's understanding of physical (non-psychosomatic) disease processes. When an objective test invented which is able to prove the psychosomatic origins of a specific illness, that illness typically disappears and is replaced by new, undiagnosable sets of symptoms.^[22]
• Patients and their advocates usually reject the suggestion that their disease may be non-physical in origin. Doctors frequently avoid giving psychosomatic diagnosis, for fear of angering patients or prompting them to switch doctors.^[22]. "Psychosomatic" is often misunderstood to mean "faking it" or "imaginary". ^[22] Other psychosomatic diseases have been known to cause severe pain, paralysis, seizures^[22], observable physical damage, even death.^[25].

A common theme among different subtypes of RSI is a stigmatization and demonization of hand use. Illness concepts that stigmatize hand use have the potential to create more illness as well-documented in the experience with the Australian RSI epidemic. ^[6] RSI was first diagnosed in Australia in the 1980s. (Only later was it diagnosed in the US and Britain.) In the early Australian experience, RSI cases increased rapidly over several years, leading to widespread media coverage and worker protests. After a widely publicized court case in which a judge ruled an alleged RSI victim had no bodily injury and could not receive damages, complaints dropped off rapidly. Many observers felt that the media coverage and social mobilization against the epidemic had actually helped spread it by causing psychosomatic symptoms in worried workers.^[26] This pattern has been seen in other psychosomatic illnesses.^[22].

Footnotes

References

References that support or promote use of the physical illness concept of RSI

• Repetitive Strain Injury: A Computer User's Guide; Emil Pascarelli and Deborah Quilter (ISBN 0-471-59533-0)
• It's Not Carpal Tunnel Syndrome! RSI Theory and Therapy for Computer Professionals; Suparna Damany, Jack Bellis (ISBN 0-9655109-9-9)
• Conquering Carpal Tunnel Syndrome & Other Repetitive Strain Injuries, A Self-Care Program; Sharon J. Butler (ISBN 1-57224-039-3)
• The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, Second Edition; Clair Davies, Amber Davies (ISBN 1-57224-375-9)
• Electromyographic Applications in Pain, Physical Medicine and Rehabilitation: Repetitive Strain Injury Computer User Injury With Biofeedback: Assessment and Training Protocol; Erik Peper, Vietta S Wilson et al. The Biofeedback Foundation of Europe, 1997
• van Tulder M, Malmivaara A, Koes B (2007). "Repetitive strain injury". Lancet 369 (9575): 1815–22. doi:10.1016/S0140-6736(07)60820-4. PMID 17531890. 

References that are cautious about the use of the physical illness concept of RSI

• Szabo RM, King KJ.Repetitive stress injury: diagnosis or self-fulfilling prophecy? J Bone Joint Surg Am. 2000 Sep;82(9):1314-22. Review.
• Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm pain. J Bone Joint Surg Am. 2004 Jul;86-A(7):1387-91.
• Quintner JL.The Australian RSI debate: stereotyping and medicine. Disabil Rehabil. 1995 Jul;17(5):256-62.
• Hall W, Morrow L.'Repetition strain injury': an Australian epidemic of upper limb pain.Soc Sci Med. 1988;27(6):645-9.
• Lucire Y. Constructing RSI: Belief and Desire. University of New South Wales Press. 2001
• Brooks, Peter. Repetitive strain injury: Does not exist as a separate medical condition. British Medical Journal. 1993

External links

• Repetitive Strain Injuries at the Open Directory Project
• Musculoskeletal disorders from the European Agency for Safety and Health at Work (EU-OSHA)
• Workrave application for prevention of RSI
• Repetitive Stress Injury at The Journal of Bone & Joint Surgery
• Harvard RSI Action
• Prevention of Repetitive Strain Injury